Healthcare Provider Details

I. General information

NPI: 1174693303
Provider Name (Legal Business Name): PONCE PLAZA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 SW 12TH AVE
MIAMI FL
33130-2011
US

IV. Provider business mailing address

335 SW 12TH AVE
MIAMI FL
33130-2011
US

V. Phone/Fax

Practice location:
  • Phone: 305-545-6695
  • Fax: 305-545-0398
Mailing address:
  • Phone: 305-545-6695
  • Fax: 305-545-0398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number11400961
License Number StateFL

VIII. Authorized Official

Name: MRS. DESIREE SEBASTIAN-SANTIAGO
Title or Position: ADMINISTRATOR
Credential: NHA
Phone: 305-545-6695